Toward a polytheoretical framework for health behavior change.
Abstract: To overcome shortcomings and boost the strength of commonly used health behavior theories, researchers have suggested combining these theories into a single, unified model. Thus, the objective was to engage in "theoretical fusion" to construct an integrated, comprehensive health behavior polytheoretical framework. The resulting polytheoretical framework represents a fusion of ideas across theories, defines each construct, depicts relationships among constructs, and cites research supporting them. It is drawn in a manner that promotes intervention design, framework testing, consistent language in research reporting, and fidelity of study replication. The polytheoretical framework is among the first attempts to integrate frequently used and emerging health behavior theories into a single framework. We hope the framework will spawn lively debate and advance research, theory application and improvement, and knowledge of health promotion intervention components that more effectively effect change.
Subject: Health behavior
Authors: Corda, Kirsten W.
Quick, Virginia
Schefske, Scott
DeCandia, Joanne
Byrd- Bredbenner, Carol
Pub Date: 09/22/2010
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Fall, 2010 Source Volume: 25 Source Issue: 4
Topic: Canadian Subject Form: Health behaviour
Accession Number: 309069163
Full Text: In 2005, the Bangkok Charter for Health Promotion in a Globalized World defined health promotion as "the process of enabling people to increase control over their health and its determinants, and thereby improve their health" (Participants of the 6th Global Conference on Health Promotion, 2005). To facilitate this process, health educators must understand the determinants of health behaviors as well as how and why behavior change occurs. Then, they must apply this knowledge to create and implement strategies that help individuals modify health behaviors and, subsequently, evaluate the strategies and monitor individuals' progress toward improved health (Glanz, Rimer, & Viswanath, 2008c; Noar & Zimmerman, 2005).

In the last 60 years, myriad health behavior theories have emerged to promote understanding of predictors of health behaviors and behavior change and to serve as roadmaps for intervention planning and evaluation (Nigg, Allegrante, & Ory, 2002). A theory is defined as "a set of interrelated concepts [Note 1], definitions, and propositions that present a systematic view of events or situations by specifying relations among variables, in order to explain and predict the events or situations" (Glanz et al., 2008c, p. 26) [Note 2]. As a whole, these theories are useful and have helped advance the field. However, the smorgasbord of health behavior theories available presents challenges for health promotion practitioners and researchers deciding which theories to use and how to apply them to their work as well as challenges for those seeking to understand and differentiate among them (Cerin, Barnett, & Baranowski, 2009; Glanz et al., 2008c). In addition, the predictive value of the theories tends to be quite modest, with no single theory consistently outperforming others (Baranowski, Cullen, & Baranowski, 1999; Baranowski, Cullen, Nichlas, Thompson, & Baranowski, 2003; Brug, 2006; Cerin et al., 2009; Resnicow & Vaughan, 2006; Rothman, 2004).

To overcome the challenges associated with the use of theories, some have suggested conducting studies that compare models to find the one that is most useful in explaining behavior change (Weinstein, 1993). But, as Maddux (1993) pointed out, numerous studies have not led to a consensus on which model is most useful. Furthermore, these studies are unlikely to be productive given the strong similarities among models (Maddux, 1993). "A better approach is to attempt to incorporate the major features of the relevant models into a single model and then attempt to determine the relative importance of the features of the new inclusive model" (Maddux, 1993, p.132). Other researchers also have encouraged the integration of health behavior theories to create a more comprehensive "polytheoretical" theory (Achterberg & Miller, 2004; Baranowski, 1989/90, 2006; Baranowski et al., 1999; Baranowski et al., 2003; Hagger, 2009; Nigg & Jordan, 2005; Prochaska, Redding, & Evers, 2008). In fact, "combinations of theories are becoming the norm in health behavior change interventions" (Rimer, 2008, p.42).

An analysis of the most commonly used behavior change theories (Glanz et al., 2008c; Noar, Chabot, & Zimmerman, 2008) reveals several key challenges must be overcome to create a single comprehensive theory (Nigg et al., 2002; Noar, 2005-2006). One challenge is that many constructs are known to affect health behavior, yet the most commonly used theories incorporate few constructs despite the complexity of human behavior. Another challenge is that commonly used health behavior theories share similar (or indistinguishable) constructs and/or posit similar relationships among constructs (Achterberg & Miller, 2004; Baranowski et al., 1999; Elder, Ayala, & Harris, 1999; Glanz et al., 2008c; Institute of Medicine, 2002; Maddux, 1993; Nigg et al., 2002; Noar, 2005-2006; Noar et al., 2008; Noar, Laforge, Maddock, & Wood, 2003; Noar & Zimmerman, 2005; Rothman, 2004; Schuz, Sniehotta, Mallach, Wiedemann, & Schwarzer, 2009; Schwarzer, 2001; Weinstein, 1993), thereby "creating the illusion that they are different" and causing a "fragmented literature" (Noar & Zimmerman, 2005, p. 277). Numerous researchers have called for identifying conceptual commonalities among theories (Achterberg & Miller, 2004; Baranowski et al., 1999; Maddux, 1993; Noar, 2005-2006; Noar & Zimmerman, 2005; Schwarzer, 2001) in hopes that the elimination of duplication will improve health promotion research, evaluation, theory application, and intervention effectiveness (Achterberg & Miller, 2004; Baranowski et al., 1999; Hagger, 2009; Weinstein, 1993). Examples of efforts to harmonize constructs include the work of Baranowski (Baranowski, 1992/93), Maddux (Maddux, 1993), Devries (deVries, 2008), and Noar (Noar, 2005-2006; Noar & Zimmerman, 2005) who identified similarities among constructs from several behavioral theories, including the Health Belief Model (Baranowski, 1992/93; Champion & Skinner, 2008), Theory of Reasoned Action (Baranowski, 1992/93; Fishbein, 1967; Montano & Kasprzyk, 2008), Theory of Planned Behavior (Ajzen, 1991; Montano & Kasprzyk, 2008), Social Cognitive Theory (Bandura, 2004; Baranowski, 1992/93; McAlister, Perry, & Parcel, 2008), Transtheoretical Model (Prochaska et al., 2008), and Precaution-Adoption Process Model (Weinstein, Sandman, & Blalock, 2008). In a comparison of stage-based theories, Schuz and colleagues (Schuz et al., 2009) concluded that the Transtheoretical Model (Prochaska et al., 2008), Precaution-Adoption Process Model (Weinstein et al., 2008), Integrated Change (I-Change) Model (deVries, Mesters, van de Steeg, & Honing, 2005; Smeets, Kremers, deVries, & Brug, 2007), Health Action Process Approach (Schwarzer, 2001), and Model of Action Phases (Gollwitzer, 1996), although differing in the number and description of stages, all share the conceptual commonality that behavior change progresses through a series of critical transitions. That is, these theories, supported by strong evidence, posit that behavior change proceeds from "preintention" (i.e., not intending to behave) to intention (i.e., forming an explicit behavioral intention or motivation) to action (i.e., actually engaging in the behavior) (Schuz et al., 2009; Weinstein, Rothman, & Sutton, 1998).

Health behavior theories focusing on the individual or personal level tend to be either stage-based or decision-oriented (Weinstein et al., 2008). Stage-based theories describe how behavior change proceeds. Decision-oriented theories (e.g., Health Belief Model [Champion & Skinner, 2008], Theory of Reasoned Action [Fishbein, 1967; Montano & Kasprzyk, 2008], Theory of Planned Behavior [Ajzen, 1991; Montano & Kasprzyk, 2008]) describe the determinants of health behavior and seek to explain why a behavior is (or will be) practiced (Noar et al., 2008; Rimer, 2008). Although the stage-based Transtheoretical Model shares conceptually similar constructs (e.g., decisional balance, self efficacy) with some decision-oriented theories (Noar & Zimmerman, 2005), a challenge associated with commonly used health behavior change theories is that they do not integrate the how of stage-based with the why of decision-oriented models (Baranowski, 1989/90; Noar, 2005-2006; Schuz et al., 2009). Few research efforts have been made to incorporate ideas from stage-based and decision-oriented theories (Baranowski, 1989/90; deVries et al., 2005; Lippke & Plotnikoff, 2009; Prochaska et al., 2008) despite the potential such a combination offers for advancing health behavior research and intervention development (Lippke & Plotnikoff, 2009).

Health behaviors are affected by and, in turn, affect, multiple levels or spheres of influence (i.e., personal, social environment, and physical environment) (Baranowski, 1989/90; Glanz, Rimer, & Viswanath, 2008b; Noar & Zimmerman, 2005). Although all spheres of influence affect health behavior simultaneously and reciprocally, a further challenge posed by the most frequently used health behavior theories is that they tend to focus only on a single level of influence (typically personal [Glanz et al., 2008b; Noar & Zimmerman, 2005]) and do not integrate the multiple spheres of influence into a single theory (Baranowski, 1989/90; Glass & McAtee, 2006; Lytle, 2005). Efforts to merge multiple spheres of influence into a single theory include the Integrated Behavioral Model (Fishbein, 2000; Fishbein & Cappella, 2006), an outgrowth of the Theory of Reasoned Action (Fishbein, 1967; Montano & Kasprzyk, 2008) and Theory of Planned Behavior (Ajzen, 1991; Montano & Kasprzyk, 2008), and the General Model of Determinants of Behavior Change proposed by the Institute of Medicine (Fishbein, 2000; Fishbein & Cappella, 2006; Institute of Medicine, 2002).

To cope with the shortfalls of commonly used health behavior theories, researchers and practitioners frequently must combine aspects of two or more theories to capture a fuller array of constructs, behavior change stages, decision determinants, and/or spheres of influence needed to guide their work (Spahn et al., 2010). A "polytheoretical model.. .awaits development" (Achterberg & Miller, 2004, p. 41), thus the authors endeavored to build on the work of many others (e.g., Baranowski, 1989/90, 1992/93; Chapman & Ogden, 2009; deVries, 2008; deVries et al., 2005; Fishbein, 2000; Fishbein & Cappella, 2006; Institute of Medicine, 2002; Maddux, 1993; Noar & Zimmerman, 2005; Schuz et al., 2009; Weinstein, 1993) by engaging in "theoretical fusion" to construct an integrated, comprehensive, unifying polytheoretical framework for health behavior change. This process, in the words of Nobel Prize recipient Roald Hoffman, was one where existing "models become modules in a theoretical Erector set" (Hoffman, 2003, p.10).

FRAMEWORK DEVELOPMENT

The polytheoretical framework grew out of a series of focused discussions among a group of nine health and nutrition educators (including the authors) occurring over a period of approximately six months. The goals of the discussions were to 1) critically and systematically examine commonly used health behavior theories focusing on behavior change in which individuals are involved actively and intentionally (Chapman & Ogden, 2009; Nigg, 2001) [Note 3], 2) iteratively differentiate and/or combine constructs similarly conceptualized across theories, and 3) identify gaps between theories related to influencing behavior change.

"Studying multiple theories simultaneously allows for empirically driven integration of theories and may lead to the construction of a more complete or holistic theory of health behavior change than currently exists. And can help us learn more about the behavior change process than does the study of any theory in isolation, and thus, better guide intervention development" (Nigg et al., 2002, p.671). Therefore, the most commonly used theories identified by Glanz et al (Glanz et al., 2008c) and their core constructs were studied individually in detail to promote depth of knowledge and a common understanding. These included the Health Belief Model, Theory of Reasoned Action/Theory of Planned Behavior/Integrated Behavioral Model, Transtheoretical Model, Social Cognitive Theory, Social Support and Social Networks, and Ecological Model, as well as the Precaution-Adoption Process Model. To promote integration of knowledge across theories, commonalities were identified using a sequential, iterative process (see Table 1). That is, after examining a theory and related research in detail, the theory was compared with all previously studied theories and models to define and combine similar constructs (see Table 2), identify research-supported relationships among constructs, and to integrate additional constructs. In addition, to describe constructs promoting stepwise progression of behavior change, decision-oriented theories were integrated into stage-based theories using published research findings and the health and nutrition educators' expertise. To demonstrate the multiple levels influencing health behavior, personal-oriented theories were nested within social and physical environment-oriented theories. Scrutiny of the drafted polytheoretical framework revealed important constructs were missing from the most commonly used and emerging models used to create the framework. Hence, additional theories were examined (i.e., communication theories [Finnegan & Viswanath, 2008] and Transactional Model of Stress and Coping [Glanz & Schwartz, 2008]) and salient constructs were added to the framework.

FRAMEWORK COMPONENTS

The framework offered in Figure 1 represents a fusion of ideas across theories. Each of the core constructs has been used in a wide array of studies across a broad range of health behaviors and population groups (see Figure 1 footnote labeled Numbered Pathways for a sampling of the many studies supporting the inclusion of the constructs and their relationships to behavior change). The framework was drawn in a manner to promote intervention design, framework testing, consistent language in research reporting (Table 2), and fidelity of study replication. The framework indicates that behavior change progresses along the seven stages proposed by the Precaution-Adoption Process Model (Weinstein et al., 2008), with the first 3 stages collectively being 'preintention', the next 2 stages being intention to (or not to) act, and the last stages being action (see Figure 1a). It also denotes constructs (e.g., personal agency, outcome expectations; see Figure 1b) from multiple spheres (i.e., physical environment, social environment, and personal; see Figure 1c) that influence movement from preintention to intention and then to action. The framework also recognizes that change processes, such as those associated with the Transtheoretical Model, can be used by health professionals to encourage progress through stages (Prochaska et al., 2008).

[FIGURE 1a OMITTED]

[FIGURE 1b OMITTED]

[FIGURE 1c OMITTED]

[FIGURE 1d OMITTED]

Unawareness to Engagement. To move from preintention to intention, individuals must be aware of and engaged by an issue (i.e., a health behavior in need of change). As depicted in Figure 1b, cues to engagement include the effect of Environmental Conditions (Pathway 1) and Observational Learning (Pathway 2) on Internal Resources (Pathway 3). Note that examples of published research supporting each of the pathways are cited in Figure 1d. The cues to engagement are described as follows.

* Environmental Conditions are physical and social factors external to the person that affect behavior. External factors may be barriers and benefits (i.e., any potentially negative or positive physical or psychosocial aspect of a behavior) (Champion & Skinner, 2008) or facilitators (i.e., tools, resources, and opportunities necessary to promote decision-making to perform a behavior) (McAlister et al., 2008). The Physical Environment includes the information environment (information availability and accessibility, message source, content, tone), health behavior specific environment (e.g., food environment includes availability and accessibility of food), technological environment (development and distribution of technological advances), and health care environment (availability and accessibility of health care professionals, facilities, and health promotion programs). The Social Environment (interpersonal relations; social status, societal inclusion/exclusion, and (in) equality; and social organizations such as family, worksites, schools) includes culture (socially transmitted knowledge, behaviors, experience, beliefs, values, attitudes, meanings, hierarchies, and roles that distinguish members of one group), social support (psychological/emotional and tangible support and services), economic environment (purchasing power), and political environment (policies, laws, and regulations affecting behaviors) (Champion & Skinner, 2008; deVries et al., 2005; Maddux, 1993; Montano & Kasprzyk, 2008; Resnicow & Vaughan, 2006; Weinstein et al., 2008).

* Observational Learning is the learning of behaviors modeled by other people one observes directly or vicariously (e.g., via media) (Finnegan & Viswanath, 2008; McAlister et al., 2008).

* Internal Resources are one's psychological and physical assets or capital that can be drawn upon to accomplish a goal. Internal resources are comprised of an individual's knowledge (e.g., understanding of a health issue and the value of taking a specific action; health literacy [Champion & Skinner, 2008]; prior experience and psychological reactions to a behavior, articles [e.g., exercise equipment, dietary regimens, medications], and persons [e.g. health professionals] associated with a behavior); abilities and skills (e.g., demonstrated ability to use one's knowledge to make decisions and physically take an action, including self-regulation skills); psychology (e.g., personality characteristics, mental health status, resilience, adaptability, personal epiphany [Almedom & Glandon, 2007; Antonovsky & Sourani, 1988; deVries et al., 2005; Miller, 2004; Resnicow & Vaughan, 2006]); biology (e.g., gender, genetic factors, physical health status, physical symptoms, addictions, life stage, weathering [physical changes resulting from social adversity] [Baranowski et al., 2003; deVries et al., 2005; Geronimus, 2001; Glanz & Oldenburg, 2001]); and habits and lifestyle that moderate the ability to take action on oneself or one's environment. Internal Resources influence Outcome Expectations (Pathway 4).

* Outcome Expectations are an individual's beliefs about the likelihood (susceptibility and threat risk) and significance of the consequences of a behavioral choice (severity) (Champion & Skinner, 2008; Finnegan & Viswanath, 2008; McAlister et al., 2008; Weinstein et al., 2008), and includes aspects of coping and self-efficacy (deVries, Dijkstra, & Kuhlman, 1988).

Engagement to Decision. Moving from being engaged with an issue to a decision to act (or not act) is influenced by several cues to intention decision, including Social Norms, Attitudes, and Personal Agency (Pathway 5, Pathway 6, Pathway 7, respectively), which are described below.

* Social Norms are implicit and explicit rules that define "appropriate" attitudes and behaviors of a culture thereby exerting pressure to believe and behave in a certain way (Finnegan & Viswanath, 2008; Montano & Kasprzyk, 2008). Social Norms are collectively based on beliefs about what important others (e.g., friends, families, colleagues) expect in one's behavior and one's motivation to comply with expectations (Social Expectations) and perceptions of how others behave (Perceived Norms) (Fishbein & Cappella, 2006; Montano & Kasprzyk, 2008). Social Norms are "flavored" by Outcome Expectations (expectations for approval and support of behavior) (Pathway 8) (Heaney & Israel, 2008; Maddux, 1993). The Social Environment, especially culture (which includes traditional definitions of ethnicity, race, and/or religion as well as social and personal networks), influences Social Norms (Pathway 9).

* Attitude (beliefs, feelings, and values about performing a specific behavior) exerts a strong influence on whether one decides or intends to act (Armitage & Christian, 2003; Noar et al., 2008). Attitudes include the sum of emotions about performing a specific behavior (Experiential Attitude) weighted (pro vs. con) by cognitive evaluations of these beliefs (Instrumental Attitude) (Montano & Kasprzyk, 2008; Noar, 2005-2006) and perceived importance of engaging in a behavior (Salience of Behavior) (Becker, 1974; Montano & Kasprzyk, 2008). Attitudes are shaped by Outcome Expectations and Social Norms (Pathway 10 and Pathway 11, respectively) (Maddux, 1993).

* Personal Agency (i.e., one's perceived and actual capacity to perform or exert power over a behavior and its antecedents and environmental context) is a type of Internal Resource and is influenced by Social Norms (Pathway 12). The components of Personal Agency are as follows.

Perceived Control is belief in the likelihood of successfully controlling and managing oneself as well as Environmental Conditions to enact the behavior (Montano & Kasprzyk, 2008; Smith et al., 2000; Weinstein, 1993).

Coping Capacity is the ability to identify and effectively use available strategies for managing behavioral performance and associated psychological/emotional and environmental consequences.

Self-Regulation involves controlling one's behavior and psychological state through self monitoring and appraisal, self contracting, goal setting and planning, feedback, self reward and reinforcement, self instruction, coping skills, enlistment of social support and reinforcement, and/or restructuring the physical environment (Baranowski, 1989/90; McAlister et al., 2008).

The type of Self Regulation used during movement from preintention to intention focuses on action planning whereas progression to action and maintenance focuses on coping planning (Schuz et al., 2009; Sniehotta, Schwarzer, Scholz, & Schuz, 2005).

Self-Efficacy, influenced by Perceived Control, Self Regulation, and Coping Capacity (Bandura, 1997), is one's belief in his or her ability to perform a specific behavior that will bring about desired outcomes (McAlister et al., 2008; Montano & Kasprzyk, 2008; Prochaska et al., 2008; Schwarzer, 2001; Weinstein et al., 2008) and effectively cope with the consequences (emotions, outcomes) (deVries et al., 1988; Noar et al., 2008) and temptations (Prochaska et al., 2008). Self-efficacy develops through actual and vicarious experience (physical environment sphere), persuasive efforts by others (social sphere), psychological and physiological information (personal sphere) (deVries et al., 1988). Different types of self-efficacy (e.g., social, stress, skills, routine) may exist (deVries et al., 2005).

Intention to Act to Action. Progression from intention to perform a health protective behavior to actually performing it (Pathway 13) is influenced by cues to action, including Salience of Behavior (Pathway 14), Environmental Conditions (Pathway 15), Personal Agency (Pathway 16, especially the Self-Regulation component Pathway 17). Self-Regulation (Pathway 18) in particular and Attitude (Pathway 19) also promote maintenance of the behavior. To support progression through the stages, the framework recognizes the importance of matching intervention tools and strategies (e.g., change processes [Prochaska et al., 2008]) to the individuals stage of change.

CONCLUSION AND IMPLICATIONS

The "fusion" theory proposed in Figure 1 is a synthesis of the commonly used health behavior theories and research documenting the relationships among constructs into a single model (see Figure 1d for references of supporting research). By enhancing the Precaution Adoption Process Model (Weinstein et al., 2008), the proposed framework describes both the how and why of behavior change and places change within the context of multiple spheres of influence. However, like other health behavior theories on which it is based, the proposed theoretical framework falls short of indicating the relative importance of each construct on behavior intention or action. Likely future research will determine that a construct's importance in promoting behavior change will vary depending on the behavior of interest, the individual's demographic and psychographic characteristics (Baranowski, 1989/90; Byrd-Bredbenner, Abbot, & Cussler, 2008), and ultimate goal of the intervention (e.g., increase awareness vs. change behavior) (deVries et al., 1988; Glanz & Oldenburg, 2001). This theoretical framework and most theories on which it is based also do not consider cultural, psychographic, or demographic appropriateness, message framing (e.g., fear appeals), or methods for reliably assessing changes in behavior determinants or behavior itself (Baranowski et al., 2003; Maddux, 1993). Further, the paucity of published research from existing theories causes the proposed framework to suffer from a lack of specificity regarding constructs that promote progression through the preintention stages.

For a theory to be accepted it must tell a story that is logical and clear, be designed so that others beyond the developers can independently use it, provide an accurate account of the factors that regulate multiple health behaviors, demonstrate predictive power, and stimulate application and experimentation (Achterberg & Miller, 2004; Bandura, 1977; Glass & McAtee, 2006; Hoffman, 2003; van Ryn & Heaney, 1992). To promote the use of this fusion of extant theories, we have endeavored to construct it in a lucid and rational manner and base it on a wide array of published research. To increase clarity of the framework and facilitate independent use by others, each construct has been clearly defined, with definitions derived from the work of many others (see Table 2). This framework also has the potential to be broadly applied because research focusing on widely varying health behaviors was used to identify its constructs and elucidate the relationships among them (see example references cited in Figure 1d). Given the array of health behaviors (e.g., one time behaviors such as radon testing, occasional behaviors such as mammograms, and nearly constant and complex collections of behaviors, such as healthy eating, engaging in exercise, avoiding tobacco) and audience segments, the relative importance of each construct vis-a-vis specific health interventions may vary (Institute of Medicine, 2002; Rothman, 2004). Nonetheless, the framework provides a more holistic view of the multitude of factors affecting health behavior change which could better inform health intervention planning and development of evaluation protocols, stimulate research to determine the relative importance of constructs, lead to more effective interventions, and result in greater predictive power than the less comprehensive behavior change models on which it is based (Baranowski, 1992/93; Brug, 2006; Hagger, 2009; Resnicow & Vaughan, 2006; Rothman, 2004).

The usefulness and predictive power of the proposed "fusion" theory will be known only when researchers and practitioners are stimulated to apply and experiment with it across a range of health behaviors, settings, and audience segments (Achterberg & Miller, 2004; Baranowski, 2006; Byrd-Bredbenner et al., 2008; Resnicow & Vaughan, 2006; Rothman, 2004); describe the techniques and strategies used to influence constructs in efforts to up- or down-regulate health behaviors (e.g., overeating, exercising) (Cerin et al., 2009; Glass & McAtee, 2006); describe the evaluation methods used to measure changes in constructs and behavior, including psychometric data (Cerin et al., 2009); share health and behavior outcomes from programs guided by it; explore interactions within constructs (e.g., different environments) (Bandura, 1977, 2004; Committee on Health and Behavior: Research, Board on Neuroscience and Behavioral Health, Institute of Medicine, & Sciences, 2001; Glass & McAtee, 2006; Kremers et al., 2006); describe possible non-linear relationships among constructs (Resnicow & Vaughan, 2006); and propose revisions, expansions, or whole new "fusion" theories (Maddux, 1993).

Those favoring a parsimony paradigm of theory development may view the framework's complexity as a limitation to its usefulness. Parsimony (also called Occam's razor), the preference for a simpler explanation of a phenomenon over a more complex account, has long been preferred in theory development. However, as Sowers and Dulmas point out, "simple explanations must provide a sufficient account. A mere preference for simplicity is not what parsimony is all about--otherwise we could explain everything by saying that God did it! But science deals with naturalistic accounts, not supernatural ones. An elegantly simple theory that failed to provide an adequate explanation would not conform to this principle of parsimony." (Sowers & Dulmas, 2008, p.xxii). We concede that the proposed framework is complex because it is attempting to explain human health behavior, which is inherently complex and occurs within an ultra-complex environment (Glass & McAtee, 2006). Additionally, the purpose of this framework is to overcome the modest predictive power of existing, more parsimonious theories (Baranowski et al., 1999; Baranowski et al., 2003; Brug, 2006; Cerin et al., 2009; Resnicow & Vaughan, 2006; Rothman, 2004), which necessitates the expansion of individual theories to a more comprehensive, unified pan-theoretical view of behavior change (Achterberg & Miller, 2004; Baranowski, 2006; Baranowski et al., 1999; Baranowski et al., 2003; Hagger, 2009; Nigg & Jordan, 2005). We contend that the principle of parsimony can be applied effectively only after all salient factors affecting health behaviors have been identified and their relative importance determined--much like using factor analysis or regression to identify the strongest variables in a set. The holistic nature of the proposed framework will make empirical testing challenging, but not impossible. The individual components (i.e., constructs and relationships between them) already have been established by numerous studies across a variety of health behaviors (Glanz et al., 2008c) (see, for example, references in Figure 1d and Glanz et al [Glanz, Rimer, & Viswanath, 2008a]). Building on existing studies by incorporating an increasingly broader range of constructs will help to determine the overall usefulness of the framework offered here and identify the most salient constructs, thereby possibly and eventually yielding a parsimonious model.

We recognize that we have taken a bold step in seeking to nudge the evolution of health behavior theory by proposing unified construct descriptions and a synthesis of extant models into this polytheoretical framework. We expect some readers will disagree with aspects of the construct definitions and the framework. Nonetheless, we hope it will spawn lively debate and advance research, theory application and improvement, and knowledge of health promotion intervention components that more effectively effect change. After all, "theories are dynamic entities that should evolve overtime" (Weinstein & Rothman, 2005, p. 296).

AUTHORS' CONTRIBUTIONS

All authors participated in the conceptualization of the framework, were involved in drafting or revising the manuscript, and have read given final approval for this version to be published.

ACKNOWLEDGEMENTS

The authors wish to thank the following individuals for their help in developing aspects of the framework: Carolina Espinosa, Deepika Sekri, Maria Courel, and Jonathan M. Brown.

DECLARATION OF COMPETING INTERESTS

The authors declare that they have no competing interests.

REFERENCES

Achterberg, C., & Miller, C. (2004). Is one theory better than another in nutrition education? A viewpont: More is better. Journal of Nutrition Education and Behavior, 36, 40-42.

Ajzen, I. (1991). The theory of planned behavior. Organizational behavior and human decision processes, 50, 179-211.

Ajzen, I., & Madden, J. (1986). Prediction of goal-directed behavior: Attitudes, intentions, and perceived behavioral control. Journal of Experimental Social Psychology, 22, 453-474.

Albarracin, D., C., Johnson, B., & Muellerleile, P. (2001). Theories of Reasoned Action and Planned Behavior as Models of Condom Use; A Meta-Analysis. Psychological Bulletin, 127, 142-161.

Almedom, A., & Glandon, D. (2007). Resilience is not the absence of PTSD any more than health is the absence of disease. J Loss and Trauma, 12, 127-143.

Antonovsky, A., & Sourani, T. (1988). Family sense of coherence and family adaptation. Journal of Marriage and Family Therapy, 50, 79-92.

Armitage, C., & Christian, J. (2003). From attitudes to behaviour: Basic and applied research on the Theory of Planned Behavior. Current Psychology: Developmental, Learning, Personality, Social, 22, 187-915.

Bandura, A. (1977). Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall.

Bandura, A. (1986). Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall.

Bandura, A. (1997). Self-efficacy: The Exercise of Control. New York: W. H. Freeman.

Bandura, A. (2004). Health promotion by social cognitive means. Health Educ Behav, 31, 143-164.

Baranowski, T. (1989/90). Reciprocal determinism at the stages of behavioral change: an integration of community, personal and behavioral perspectives. International Quarterly of Community Health Education, 10, 297-327.

Baranowski, T. (1992/93). Beliefs as motivational influences at stages in behavior change. International

Quarterly of Community Health Education, 13, 3-29. Baranowski, T. (2006). Crisis and chaos in behavioral nutrition and physical activity. International Journal of

Behavioral Nutrition and Physical Activity, 3, 27-31. Baranowski, T., Cullen, K., & Baranowski, J. (1999). Psychosocial Correlates of Dietary Intake: Advancing Dietary Intervention. Annual Review of Nutrition, 19, 17-40.

Baranowski, T., Cullen, K., Nichlas, T., Thompson, D., & Baranowski, J. (2003). Are current health behavioral change models helpful in guiding prevention of weight gain efforts? Obesity Research, 11, 23S-43S.

Becker, H. (1974). The Health Belief Model and personal health behavior. Health Education Monographs, 2, 324-473.

Brewer, N., & Rimer, B. (2008). Perspectives on health behavior theories that focus on individuals. In K. Glanz, B. Rimer & K. Viswanath (Eds.), Health Behavior and Health Education. Theory, Research, and Practice (4 ed.). San Francisco: Jossey-Bass.

Brug, J. (2006). Order is needed to promote linear or quantum changes in nutrition and physical activity behaviors: A reaction to 'A chaotic view of behavior change' by Resnicow and Vaughan. International Journal of Behavioral Nutrition and Physical Activity, 3, 29-32.

Brug, J., Glanz, K., & Kok, G. (1997). The relationship between self-efficacy, attitudes, intake compared to others, consumption, and stages of change related to fruit and vegetables. American Journal of Health Promotion, 12, 25-30.

Brug, J., Hospers, K., & Kok, G. (1997). Differences in psychosocial factors and fat consumption between stages of change for fat reduction. Psychology & Health, 12, 719-727.

Byrd-Bredbenner, C., Abbot, J., & Cussler, E. (2008). Psychographic Segmentation of Mothers of Young Children Using Food Decision Influencers. Nutrition Research, 28, 506-516.

Cerin, E., Barnett, A., & Baranowski, T. (2009). Testing theories of dietary behavior change in youth using the mediating variable model with intervention programs. Journal of Nutrition Education and Behavior, 41, 309-318.

Champion, V., & Skinner, C. (2008). The Health Belief Model. In K. Glanz, B. Rimer & K. Viswanath (Eds.), Health Behavior and Health Education. Theory, Research, and Practice (4 ed.). San Francisco: Jossey-Bass.

Chapman, K., & Ogden, J. (2009). How do people change their diet? An exploration into mechanisms of dietary change. Journal of Health Psychology, 14, 1229-1242.

Committee on Health and Behavior: Research, P., and Policy,, Board on Neuroscience and Behavioral Health, Institute of Medicine, & Sciences, N. A. o. (2001). Health and behavior: The interplay of biological, behavioral, and societal influences committee on health behavior. Washington, DC: National Academy Press.

deVries, H. (2008). The I-Change Model. Retrieved June 16, 2009, from http://www.personeel.unimaas.nl/ hein.devries/I-Change.htm

deVries, H., Dijkstra, M., & Kuhlman, P. (1988). Self-efficacy: The third factor besides attitude and subjective norm as a predictor of behavioural intentions. Health Education Research, 3, 273-282.

deVries, H., & Mudde, A. (1998). Predicting stage transitions for smoking cessation applying the attitude social influence-efficacy model. Psychology & Health, 13, 369-385.

deVries, H., Mesters, I., van de Steeg, H., & Honing, C. (2005). The general public's information needs and perceptions regarding hereditary cancer: an application of the Integrated Change Model. Patient Education and Counseling, 56, 154-165.

Elder, J., Ayala, G., & Harris, S. (1999). Theories and Intervention Approaches to Health-Behavior Change in Primary Care. American Journal of Preventive Medicine, 17, 275-284.

Finnegan, J., & Viswanath, K. (Eds.). (2008). Communication theory and health behavior change: The media studies framework (4 ed.). San Francisco: Jossey-Bass.

Fishbein, M. (1967). Readings in attitude theory and measurement. New York: Wiley.

Fishbein, M. (2000). The role of theory in HIV prevention. AIDS Care, 12, 273-278.

Fishbein, M., & Cappella, J. (2006). The role of theory in developing effective health communications. Journal of Communications, 56, S1-S17.

Gerbner, G., Gross, L., Morgan, M., Signorielli, N., & Shanahan, J. (2002). Growing Up with Television: Cultivation Processes. In J. Bryant & D. Zillmann (Eds.), Media Effects: Advances in Theory and Research. Mahway, N.J: Lawrence Erlbaum Associates.

Geronimus, A. T. (2001). Understanding and Eliminating Racial Inequalities in Women's Health in the United States: The Role of the Weathering Conceptual Framework. Journal of the American Medical Women's Association, 56, 133-136.

Glanz, K., & Oldenburg, B. (2001). Utilizing theories and constructs across models of behavior change. In R. Patterson (Ed.), Changing patient behavior: Improving outcomes in health and disease management. San Francisco: Jossey-Bass.

Glanz, K., Rimer, B., & Viswanath, K. (Eds.). (2008a). Health Behavior and Health Education. Theory, Research, and Practice (4 ed.). San Francisco: Jossey-Bass.

Glanz, K., Rimer, B., & Viswanath, K. (Eds.). (2008b). The scope of health behavior and health education (4 ed.). San Francisco: Jossey-Bass.

Glanz, K., Rimer, B., & Viswanath, K. (Eds.). (2008c). Theory, research, and practice in health behavior and health education (4 ed.). San Francisco: Jossey-Bass.

Glanz, K., & Schwartz, M. (Eds.). (2008). Stress, coping, and health behavior (4 ed.). San Francisco: JosseyBass.

Glass, T., & McAtee, M. (2006). Behavioral science at the crossroads in public health: Extending horizons, envisioning the future. Social Science & Medicine, 62, 1650-1657.

Gollwitzer, P. (1996). Volitional Benefits of Planning. In P. Gollwitzer & J. Bargh (Eds.), The psychology of action (pp. 287-312). New York: Guilford Press.

Gollwitzer, P., & Sherran, P. (2006). Implementation intentions and goal achievement: A meta-analysis of effects and processes. Advances in Experimental Social Psychology, 38, 69-119.

Hagger, M. (2009). Theoretical integration in health psychology: Unifying ideas and complementary explanations. British Journal of Health Psychology, 14, 189-194.

Heaney, C. A., & Israel, B. (2008). Social Networks and Social Support. In K. Glanz, B. Rimer & K. Viswanath (Eds.), Health Behavior and Health Education. Theory, Research, and Practice (4 ed.). San Francisco: Jossey-Bass.

Hoffman, R. (2003). Why Buy That Theory? American Scientist, 91, 9-11.

Institute of Medicine. (2002). Speaking of health: Assessing health communication strategies for diverse populations. Washington, DC: National Academies Press.

Kremers, S., de Bruijn, G.-J., Visscher, T., van Mechelen, W., deVries, N., & Brug, J. (2006). Environmental influences on energy balance-related behaviors: A dual-process view. International Journal of Behavioral Nutrition and Physical Activity, 3, 9-18.

Lippke, S., & Plotnikoff, R. (2009). The protection motivation theory within the stages of the transtheoretical model--Stage-specific interplay of variables and prediction of exercise stage transitions. British Journal of Human Psychology, 14, 211-229.

Lytle, L. (2005). Nutrition education, behavioral theories, and the scientific method: Another viewpoint. Journal of Nutrition Education and Behavior, 37, 90-93.

Madden, T., Ellen, P., & Ajzen, I. (1992). A Comparison of the Theory of Planned Behavior and the Theory of Reasoned Action. Personality and Social Psychology Bulletin, 18, 3-9.

Maddux, J. (1993). Social cognitive models of health and exercise behavior: an introduction and review of conceptual issues. Journal of Applied Sports Psychology, 5, 116-140.

McAlister, A., Perry, C., & Parcel, G. (2008). How individuals, environments, and health behavior interact; Social Cognitive Theory. In K. Glanz, B. Rimer & K. Viswanath (Eds.), Health Behavior and Health Education. Theory, Research, and Practice (4 ed.). San Francisco: Jossey-Bass.

McAuley, E., Courneya, K., Rudolph, D., & Lox, C. (1994). Enhancing exercise adherence in middle-aged males and females. Preventive Medicine, 23, 498-506.

Miller, W. (2004). The phenomenon of quantum change. Journal of Clinical Psychology, 60, 453-460.

Montano, D., & Kasprzyk, D. (2008). Theory of reasoned action, theory of planned behavior, and the integrated behavioral model. In K. Glanz, B. Rimer & K. Viswanath (Eds.), Health Behavior and Health Education. Theory, Research, and Practice (4 ed.). San Francisco: Jossey-Bass.

Netemeyer, R., Burton, S., & Johnston, M. (1991). A comparison of two models for the prediction of volitional and goal-directed behaviors: A confirmatory analysis approach. Social Psychology Quarterly, 54, 87-100.

Nigg, C. (2001). Explaining adolescent exercise behavior change: A longitudinal application of the transtheoretical model. Annals of Behavioral Medicine, 23, 11-20.

Nigg, C., Allegrante, J., & Ory, M. (2002). Theory-comparison and multiple-behavior research: Common themes advancing health behavior research. Health Education Research, 17, 670-679.

Nigg, C., & Jordan, P. (2005). Commentary: It's a difference of opinion that makes a horserace... Health Education Research, 20, 291-293.

Noar, S. (2005-2006). A health educator's guide to theories of health behavior. Policy, Theory, and Social Issues, 24, 75-92.

Noar, S., Chabot, M., & Zimmerman, R. (2008). Applying health behavior theory to multiple behavior change: Considerations and approaches. Preventive Medicine, 46, 275-280.

Noar, S., Laforge, R., Maddock, J., & Wood, M. (2003). Rethinking positive and negative aspects of alcohol use: Suggestions from a comparison of alcohol expectancies and decisional balance. Journal of Studies on Alcohol, 64, 60-69.

Noar, S., & Zimmerman, R. (2005). Health behavior theory and cumulative knowledge regarding health behaviors: Are we moving in the right direction? Health Education Research, 20, 275-290.

Participants of the 6th Global Conference on Health Promotion. (2005). The Bangkok Charter for Health Promotion in a Globalized World. Paper presented at the 6th Global Conference on Health Promotion. Retrieved May 9, 2009, from http://www.who.int/healthpromotion/conferences/6gchp/ hpr_050829_%20BCHP.pdf.

Perkins, H., & Berkowitz, A. (1986). Perceiving the community norms of alcohol use among students: Some research implications for campus alcohol education programming. International Journal of the Addictions, 21, 961-976.

Prochaska, J., Redding, C., & Evers, K. (Eds.). (2008). The transtheoretical model and stages of change (4 ed.). San Francisco: Jossey-Bass.

Prochaska, J., Velicer, W., Rossi, J., Goldstein, M., Marcus, B., & Rakowski, W., et al. (1994). Stages of change and decisional balance for 12 problem behaviors. Health Psychology, 13, 39-46.

Resnicow, K., & Vaughan, R. (2006). A chaotic view of behavior change: A quantum leap for health promotion. International Journal of Behavioral Nutrition and Physical Activity, 3, 25-30.

Rimer, B. (Ed.). (2008). Models of individual health behaviors (4 ed.). San Francisco: Jossey-Bass.

Rothman, A. (2004). "Is there nothing more practical than a good theory?": Why innovations and advances in health behavior change will arise if interventions are used to test and refine theory. International Journal of Behavioral Nutrition and Physical Activity, 1, 11-17.

Rothman, A., Baldwin, A., & Hertel, A. (Eds.). (2004). Self-regulation and behavioral change: Disentangling behavioral initiation and behavioral maintenance. NY: Guilford Press.

Sallis, J., Owen, N., & Fisher, E. (Eds.). (2008). Ecological Models of Health Behavior (4 ed.). San Francisco: Jossey-Bass.

Schifter, D., & Ajzen, I. (1985). Intention, perceived control, and weight loss: an application of the theory of planned behavior. Journal of Personality and Social Psychology, 49, 843-851.

Schuz, B., Sniehotta, F., Mallach, N., Wiedemann, A., & Schwarzer, R. (2009). Predicting transitions from preintentional, intentional and actional stages of change. Health Education Research, 24, 64-75.

Schwarzer, R. (2001). Social-Cognitive Factors in Changing Health-Related Behaviors. Current Directions in Psychological Science, 10, 47-51.

Smeets, T., Kremers, S., deVries, H., & Brug, J. (2007). Effects of Tailored Feedback on Multiple Health Behaviors. Annals of Behavioral Medicine, 33, 117-123.

Smith, G., Kohn, S., Savage-Stevens, S., Finch, J., Ingate, R., & Lim, Y.-O. (2000). The Effects of Interpersonal and Personal Agency on Perceived Control and Psychological Well-Being in Adulthood The Gerontologist, 40, 458-468

Sniehotta, F., Schwarzer, R., Scholz, U., & Schuz, B. (2005). Action planning and coping planning for long term lifestyle change: Theory and assessment. European Journal of Social Psychology, 35, 565-576.

Sowers, K., & Dulmas, C. (Eds.). (2008). Comprehensive Handbook of Social Work and Social Welfare. Human Behavior in the Social Environment (Vol. 2). Hoboken, NJ: John Wiley & Sons, Inc.

Spahn, J., Reeves, R., Keim, K., Laquatra, I., Kellogg, M., Jortberg, B., et al. (2010). State of the evidence regarding behavior change theories and strategies in nutrition counseling to facilitate health and food behavior. Journal of the American Dietetic Association, 110, 879-891.

Stitt, C. (May 27, 2004). The Influence of Social Norms on Attitudes: Considering a Modified Value-Expectancy Approach. Paper presented at the International Communication Association. van Ryn, M., & Heaney, C. (1992). What's the Use of Theory? Health Educ Behav, 19, 315-330.

Wammes, B., Kremers, S., Breedveld, B., & Brug, J. (2005). Correlates of motivation to prevent weight gain: a cross sectional survey. International Journal of Behavioral Nutrition and Physical Activity, 2, 1-8.

Weinstein, N. (1993). Testing four competing theories of health-protective behavior. Health Psychology, 12, 324-333.

Weinstein, N., & Rothman, A. (2005). Commentary: Revitalizing research on health behavior theories. Health Education Research, 20, 294-297.

Weinstein, N., Rothman, A., & Sutton, S. (1998). Stage Theories of Health Behavior: Conceptual and Methodological Issues. Health Psychology, 17, 290-299.

Weinstein, N., Sandman, P., & Blalock, S. (Eds.). (2008). The precaution adoption process model (4 ed.). San Francisco: Jossey-Bass.

Zillmann, D. (2002). Exemplification Theory of Media Influence. In J. Bryant & D. Zillmann (Eds.), Media Effects: Advances in Theory and Research. Mahway, N.J: Lawrence Erlbaum Associates.

Kirsten W. Corda, MA

Virginia Quick, RD

Scott Schefske, RD

Joanne DeCandia, MS, RD

Carol Byrd-Bredbenner, PhD, RD, FADA

Note:

(1.) The terms "concepts" and "constructs" are both used to categorize the major components or building blocks of a theory (Glanz et al., 2008c). These terms frequently are used interchangeably. For consistency, the term "construct" is used in this article.

(2.) The terms "theory" and "model" often are used interchangeably or in tandem. For consistency and for brevity, the term "theory" is used in this article to connote both theories and models.

(3.) Behavior change may occur actively (individual is actively and intentionally engaged in making the change) or passively (gradual, seamless, naturalistic adaptive changes that occur spontaneously when an individual experiences aging effects, different financial circumstances, new employment, changes in marital status, or moves to a new country) (Chapman & Ogden, 2009; Nigg, 2001).

Kirsten W. Corda, MA, is a doctoral student at Rutgers, The State Universtiy of New Jersey. E-mail: kcorda@ eden.rutgers.edu, Virginia Quick, RD, is a doctoral student at Rutgers, The State Universtiy of New Jersey. E-mail: vquick@rci.rutgers.edu Scott Schefske, RD, is a doctoral student at Rutgers, The State Universtiy of New Jersey. E-mail: schefske@aesop.rutgers.edu Joanne DeCandia, MS, RD, is a doctoral student at Rutgers, The State Universtiy of New Jersey. E-mail: joanne@joannedecandia.com Carol Byrd-Bredbenner, PhD, RD, FADA, is a Professor and Extension Specialist in Nutritionat at Rutgers, The State Universtiy of New Jersey. E-mail:. bredbenner@aesop.rutgers.edu. Please address all correspondence to: Carol Byrd-Bredbenner, PhD, RD, FADA, 26 Nichol Avenue, New Brunswick, NJ 08901, 732-932-2382, 732-932-6522 fax, bredbenner@ aesop.rutgers.edu
Table 1. Comparison of Constructs in Commonly Used and Emerging
Health Behavior Models and Theories with Polytheoretical
Framework Constructs

Construct                        Health            Protection
                                 Belief            Motivation
                                  Model              Theory

Environment Cues to
Action (#)

  Physical Environment

    Information
    Environment
    Health Behavior
    Specific Environment
    Technological
    Environment
    Health Care
    Environment

  Social Environment

    Culture
    Social Support

    Economic                        X
    Environment
    Political Environment

Observational Learning

Internal Resources

  Knowledge                         X
  Abilities & Skills
  Psychology                        X
  Biology                           X
  Habits & Lifestyle

Outcome Expectations!                                  X

  Susceptibility and Threat         X                  X
  (Risk) Perceptions
  Severity Perceptions              X                  X

Social Norms (Social

Expectations & Social
  Norms)
Attitudes (Experiential &
  Instrumental)
  Salience of Behavior

Personal Agency

  Perceived Control
  Self-Efficacy                     X                  X
  Self-Regulation
  Coping Capacity

Behavior Change Occurs
  As A Series Of Steps

Change Processes

Construct                      Integrated            Social
                               Behavioral          Cognitive
                                 Model *             Theory

Environment Cues to                 X                  X
Action (#)

  Physical Environment

    Information
    Environment
    Health Behavior
    Specific Environment
    Technological
    Environment
    Health Care
    Environment

  Social Environment

    Culture
    Social Support

    Economic
    Environment
    Political Environment

Observational Learning                                 X
Internal Resources

  Knowledge                         X
  Abilities & Skills                X
  Psychology                        X
  Biology                           X
  Habits & Lifestyle                X

Outcome Expectations                                   X
  ([double dagger])

  Susceptibility and Threat                            X
  (Risk) Perceptions
  Severity Perceptions

Social Norms (Social                X
  Expectations & Social
  Norms)
Attitudes (Experiential &           X
  Instrumental)

    Salience of Behavior            X

Personal Agency

  Perceived Control                 X
  Self-Efficacy                     X                  X
  Self-Regulation                                      X
  Coping Capacity

Behavior Change Occurs
  As A Series Of Steps

Change Processes

Construct                   Social Support &   Ecological
                            Social Networks      Model

Environment Cues to
Action (#)

  Physical Environment                             X

    Information                                    X
    Environment
    Health Behavior                                X
    Specific Environment
    Technological
    Environment
    Health Care
    Environment

  Social Environment                 X             X

    Culture                          X
    Social Support
    Economic                                       X
    Environment
    Political Environment                          X

Observational Learning

Internal Resources

  Knowledge
  Abilities & Skills
  Psychology
  Biology
  Habits & Lifestyle

Outcome Expectations
  ([double dagger])

Susceptibility and Threat
  (Risk) Perceptions
  Severity Perceptions

Social Norms (Social
  Expectations & Social
  Norms)

Attitudes (Experiential &
  Instrumental)
  Salience of Behavior

Personal Agency

  Perceived Control
  Self-Efficacy
  Self-Regulation                    X
  Coping Capacity

Behavior Change Occurs
  As A Series Of Steps

Change Processes

Construct                   Transactional   Communication
                              Model of        Theories
                             Stress and
                               Coping

Environment Cues to
Action (#)

  Physical Environment

    Information
    Environment
    Health Behavior
    Specific Environment
    Technological
    Environment
    Health Care
    Environment

  Social Environment

    Culture
    Social Support
    Economic
    Environment
    Political Environment                            X

Observational Learning

Internal Resources

  Knowledge
  Abilities & Skills
  Psychology                      X
  Biology
  Habits & Lifestyle

Outcome Expectations
  ([double dagger])

  Susceptibility and Threat       X
  (Risk) Perceptions
  Severity Perceptions            X

Social Norms (Social
  Expectations & Social
  Norms)

Attitudes (Experiential &
Instrumental)

  Salience of Behavior

Personal Agency

  Perceived Control
  Self-Efficacy                   X
  Self-Regulation                 X
  Coping Capacity                 X

Behavior Change Occurs
  As A Series Of Steps

Change Processes

Construct                     Trans-       Precaution     Integrated
                            theoretical     Adoption        Change
                               Model      Process Model   (I-Change)
                                                            Model

Environment Cues to
Action (#)                                                    X

  Physical Environment                           X            X

    Information
    Environment
    Health Behavior
    Specific Environment
    Technological                                             X
    Environment
    Health Care                                               X
    Environment
                                                              X

Social Environment

  Culture                                                     X
  Social Support                                              X

  Economic                                                    X
  Environment
  Political Environment

Observational Learning           X              X             X
                             ([dagger])
Internal Resources                                            X

  Knowledge
  Abilities & Skills

  Psychology                                                  X
  Biology                                                     X
  Habits & Lifestyle                            X             X

Outcome Expectations                            X             X
  ([double dagger])

  Susceptibility and Threat      X              X             X
  (Risk) Perceptions
  Severity Perceptions

Social Norms (Social             X
  Expectations & Social      ([dagger])                       X
  Norms)
Attitudes (Experiential &        X              X             X
  Instrumental)
  Salience of Behavior
Personal Agency

  Perceived Control              X              X             X
  Self-Efficacy                  X                            X
                            ([dagger])
  Self-Regulation
  Coping Capacity

Behavior Change Occurs           X              X             X
  As A Series Of Steps

Change Processes                 X

Construct                    General Model    Polytheoretical
                            of Determinates      Framework
                              of Behavior
                                Change

Environment Cues to                X
Action (#)                                            X

  Physical Environment             X                  X

    Information
    Environment                                       X
    Health Behavior                X                  X
    Specific Environment                              X
    Technological                                     X
    Environment
    Health Care                                       X
    Environment

  Social Environment                                  X

    Culture                                           X
    Social Support                                    X

    Economic                                          X
    Environment
    Political Environment                             X

Observational Learning

Internal Resources                                    X

  Knowledge                        X                  X
  Abilities & Skills               X                  X
  Psychology                                          X
  Biology                          X                  X
  Habits & Lifestyle               X                  X

Outcome Expectations               X                  X
  ([double dagger])

  Susceptibility and Threat        X                  X
  (Risk) Perceptions
  Severity Perceptions                                X

Social Norms (Social               X                  X
  Expectations & Social
  Norms)

Attitudes (Experiential &                             X
  Instrumental)
  Salience of Behavior

Personal Agency                    X                  X

  Perceived Control                X                  X
  Self-Efficacy                                       X
  Self-Regulation                                     X
  Coping Capacity                                     X

Behavior Change Occurs             X                  X
  As A Series Of Steps

Change Processes                                      X

* Integrated Behavioral Model includes earlier iterations i.e.,
Theory of Reasoned Action and Theory of Planned Behavior.

# This row was marked when theories or models did not further
specify the types of Environment Cues to Action.

([dagger]) As part of change processes of the Transtheoretical Model.

([double dagger]) This row was marked when theories or models included
outcome expectations in addition to the subcategories below (i.e.,
susceptibility and threat perceptions and severity perceptions).

Table 2. Constructs of the Polytheoretical Framework
by Sphere of Influence

SPHERE OF INFLUENCE

PERSONAL LEVEL

Attitudes

Beliefs, feelings, and values about a state of being (e.g., body
weight/size, inactivity) or performing a specific behavior. Includes:

* Experiential Attitudes: emotions about a state of being or
  performing a specific behavior

* Instrumental Attitudes: cognitive evaluations of the pros & cons
  about a state of being or performing a specific behavior
  (decisional balance)

* Salience of Behavior: perceived importance of engaging in a
  behavior

Internal Resources

Supply of personal intellectual, psychological, and physical assets
or capital that can be drawn upon to accomplish
a goal. Includes:

* Knowledge: understanding of the health issue and value of taking
  a specific action, health literacy, prior experience (knowledge,
  skills, physical and psychological reactions related to previous
  performance of a behavior or association with articles [e.g.,
  food products, flavor experiences, exercise regimens] or
  individuals [e.g., health care professionals, family members]
  related to the behavior)

* Abilities & Skills: ability to use internal resources to make
  decisions and physically take action

* Psychology: personality characteristics, resilience, adaptability,
  mental health status, mood, personal epiphany

* Biology: factors that moderate the ability to take action on
  oneself or one's environment, including gender, genetic factors,
  physical health status, physical signs and symptoms, addictions,
  life stage (e.g., hormonal changes associated with growth and
  development), weathering (physical changes resulting from
  social adversity)

* Habits and Lifestyle: past and current behaviors

Personal Agency

A type of Internal Resource that is the perceived and actual capacity
to perform or exert power over a behavior and its antecedents and
environmental context. Includes:

* Perceived Control: belief in likelihood of successfully
  controlling and managing oneself as well as Environmental
  Conditions and Cues to enact the behavior

* Self-Efficacy: one's belief in ability to perform a specific
  behavior that will bring about desired outcomes and effectively
  cope with consequences (emotions, outcomes) and temptations

* Self-Regulation: ability to control oneself (behavior, emotions)
  through self-monitoring/self-appraisal/self-contracting, goal
  setting/planning, self-reward/reinforcement, self instruction,
  enlisting social support, and/or restructuring the physical
  environment

* Coping Capacity: ability to identify coping strategies that are
  available and likely to lead to support performance of a
  behavior and use these strategies effectively to manage
  behavioral performance and associated psychological/emotional
  and environmental consequences

Outcome Expectations

Underlying beliefs about a health behavior and its outcome
(response efficacy). Includes:

* Susceptibility and Threat (Risk) Perceptions: likelihood of
  experiencing (vulnerability to) health effects (beneficial or
  detrimental) as a result of engaging [or not engaging] in a
  behavior and the value of the consequences of a behavioral choice

* Severity Perceptions: extent to which the effects of a behavior
  are likely to affect physical, psychological, social, and/or
  economic well-being

Social Norms

Implicit and explicit rules that define "appropriate" attitudes (see
definition above) and behaviors of a culture (see definition above)
thereby exerting pressure to believe and behave in a certain way.
Includes:

* Social Expectations: beliefs about what important others expect
  in one's behavior and one's motivation to comply with expectations

* Perceived Norms: perceptions of how others behave

SPHERE OF INFLUENCE

SOCIAL ENVIRONMENT LEVEL                      PHYSICAL ENVIRONMENTAL
                                              LEVEL

Observational Learning

Learning of behaviors modeled by other
people one observes directly or vicariously
(e.g., via media)

Environment Cues To Action

Factors external to the physical person that affect behavior (these
may be barriers and benefits [potentially negative or positive
physical or psychosocial aspects, such as (un)safe neighborhoods
and working conditions and stress, that affect decision-making to
perform or performance of a behavior] or facilitators [physical or
psychosocial tools, resources, and opportunities that encourage
decision-making to perform and performance of a behavior]).
Includes three major groups: Social Environment, Physical
Environment, and Health Care Environment.

Social Environment: interpersonal
relations; social status, societal inclusion/
exclusion, and (in)equality; and
organizations such as family, worksites,
communities, and schools. Includes:

* Culture: Socially transmitted
  knowledge, behaviors, experience,
  beliefs, values, attitudes, meanings,
  hierarchies, and roles that distinguish
  members of one group; extent of
  acculturation to the prevailing
  culture; includes traditional
  definitions of ethnicity, race, and/ or
  religion as well as social and personal
  networks.
* Social Support: psychological/
  emotional support, tangible aid
  and services, informational (advice,
  suggestions) support, appraisal
  (constructive feedback for self-reevaluation)
  support
* Economic Environment: overall
  purchasing power as a result of
  employment, income, expenses, cost
  of goods and services including taxes\
* Political Environment: laws and
  regulations that affect (promote,
  restrict, modify) behaviors and
  options

Physical Environment: external surrounding and conditions in
which one lives (i.e., natural and built environment). Includes:

* Information Environment: information availability
  and accessibility, message source (media channel,
  advertising, health professionals), content (accuracy,
  comprehensiveness, readability), tone (positive,
  threatening)
* Health Behavior Specific Environment: varies with
  behavior of interest; for example: in the case of diet, this
  environment includes characteristics like food availability
  and accessibility in home and community, feeding
  styles, mealtime rituals, body image norms, nutrition
  information; in the case of exercise, this environment
  includes resources needed for exercise, such as equipment
  and space, availability of transportation and energy/time-saving
  conveniences, walkability and bikeability of the
  community; in the case of smoking, this environment
  includes cigarette access (cost, ease of purchasing) and
  environments that support the activity (e.g., smoke-free
  workplaces)
* Technological Environment: factors affecting the
  development and distribution of technological advances,
  such new products (e.g., medications), new manufacturing
  methods (e.g., those that reduce cost or increase
  accessibility), and new marketing and information
  dissemination methods (e.g., Internet)
* Health Care Environment: availability, quality, and
  accessibility of health care professionals and facilities;
  health behavior change intervention programs availability,
  quality, and accessibility

* Definitions derived from (Brewer & Rimer, 2008; Champion & Skinner,
2008; Finnegan & Viswanath, 2008; Glanz et al., 2008b, 2008c; Glanz &
Schwartz, 2008; Heaney & Israel, 2008; McAlister et al., 2008; Montano
& Kasprzyk, 2008; Prochaska et al., 2008; Rimer, 2008; Sallis et al.,
2008; Weinstein et al., 2008).
Gale Copyright: Copyright 2010 Gale, Cengage Learning. All rights reserved.